A model for treating HCV hepatitis in patients receiving methadone maintenance therapy.

INTRODUCTION: Although hepatitis C virus (HCV) is associated with substance abuse, treatment of addicts is problematic. We report the results of a pilot scheme for treatment of HCV - infected substance abusers in a methadone maintenance center (MMC). METHODS: The treatment program was carried out at a single MMC. Patients were not using illicit drugs or alcohol and received regular treatment with methadone. The program consisted of 5 stages: 1. An explanatory lecture concerning HCV (50/114 attended). 2. 25 of the 50 presented for examination including HCV RNA, genotype and viral load. 3. HCV treatment with pegylated alfa-interferon-1b and ribavarin. 4. The MMC physician and staff aided the clients' medical compliance. 5. A hepatologist (SM) volunteered his services on the basis of one 3 hourly session every 4-6 weeks, in addition to open access telephone consultation with the MMC staff physician. RESULTS: 50 of 114 HCV seropositive clients attended the initial meeting , 25 (50%) were candidates for treatment, of whom 20 were treated. 10 had genotype 3 infection, 9 genotype 1 and 1 genotype 2. The sustained virological response (SVR) on an intention-to-treat basis was 8/20 (40%). DISCUSSION: We present a model for the successful treatment of chronic HCV hepatitis in patients receiving methadone.

The treatment of autoimmune hepatitis.

Autoimmune hepatitis is an immune-mediated disease targeting hepatocytes. It is more common in middleaged Caucasian females, although may affect other patient populations and age groups. The diagnosis is made according to criteria based on the alkaline phosphatase: ALT ratio, IgG, the presence of autoantibodies, liver histology, response to therapy, and the absence of a viral, alcohol or drug etiology. More recently a simplified scoring system has been proposed. In the absence of treatment, the prognosis is very poor with a 60% three year mortality. There are guidelines on the indications for treatment and some groups of patients may not require treatment. The main element of treatment is prednisolone which decreases the 3 year mortality to 10%. Prednisolone is tapered down to 5-10 mg per day, as monotherapy or in combination with azathioprine. Approximately 80% of patients will respond to therapy with prednisolone with or without azathioprine and this should be given for at least 2 years. Remission is defined as an asymptomatic patient with serum aminotransferases that are normal or less than two-fold elevated, a normal level of IgG and inactive liver histology. Relapse occurs in up to 90% of patients following drug withdrawal. The sensitivity and specificity of liver histology to predict relapse off treatment is not high. Other treatments that have been proposed include mycophenolate mofetil, budesonide, cyclosporine A, tacrolimus, 6-MP, methotrexate, ursodeoxycholic acid, rapamycin and rituximab although experience with all these agents is limited.

Routine chest X-ray on hospital admission: does it contribute to diagnosis or treatment?

BACKGROUND: In many hospitals a routine chest X-ray is performed on admission. There are, however, scant data regarding its usefulness in contemporary patient populations. METHODS: We studied consecutive patients admitted during a 2 month period to a single department of medicine, where hospital policy mandates performing an admission CXR. Two senior clinicians not involved in the care of these patients assessed the discharge summaries for a clinical indication to perform CXR on admission, as well as its contribution to patient management (major positive, major negative, minor positive, or no contribution). RESULTS: There were 675 patients whose mean age was 64.5 +/- 17.2 years. In 19.6% (130 cases) CXR was not performed. Of the 545 CXRs done, 260 (48%) were normal. In only 128 (23.5%) did the admission CXR make a major positive contribution to diagnosis or treatment. In 61 (11.2%) it provided a minor positive contribution and in 153 (28.1%) a major negative contribution. In 184 patients (33.8%) the CXR did not affect either diagnosis or management. It made a major positive contribution to management in patients for whom there was an indication for performing the X-ray (odds ratio 10.3, P < 0.0005) and in those with a relevant finding on physical examination (OR 1.63, P = 0.110). For the 329 patients who had neither a clinical indication for performing a CXR nor an abnormal chest examination the admission CXR contributed to patient management in only 12 cases (3.6%). CONCLUSIONS: A routine admission CXR has a significant impact on patient management only in those patients in whom there are relevant findings on physical examination or a clear clinical indication for performing the test. There is no need to routinely order CXR on admission to hospital.

Perimyocarditis following streptococcal group A infection: from clinical cases to bioinformatics analysis.

BACKGROUND: Streptococcal infection is known to be associated with non-suppurative complications, including rheumatic fever. A less well recognized complication is perimyocarditis. METHODS: We report 4 cases of myocarditis in young males associated with acute streptoccal infection. Following this clinical observation we employed bioinformatic techniques to identify common epitopes between Streptococcus group A and human muscle proteins. We used Blast to search all the proteome (1697 proteins) of the Streptococcus pyogenes M1 GAS against the human proteome of 34,180 proteins. RESULTS: 4 patients with streptococcal A related myocarditis were treated and made a complete recovery. One cardiac protein, ATP2A2 (NP_733765.1)), a cardiac Ca2+ ATPase, shared an epitope with Streptococcus group A and a high probability of being presented on a MHC Class II molecule. CONCLUSION: Streptococcal myocarditis may be a commoner entity than previously appreciated. Bioinformatic techniques have identified a suspected common epitope between the streptococcal proteins and a cardiac Ca2+ ATPase.

The involvement of the liver in systemic diseases.

The liver has a double blood supply and plays a central role in the metabolism of proteins, carbohydrates, and many medications. In addition, it has a role in the induction of immune tolerance and may also be a target for immune-mediated damage. For these reasons, the liver may be involved in many systemic diseases. In this review, we discuss the involvement of the liver in granulomatous, rheumatologic, malignant, and circulatory diseases. An understanding of the wide spectrum of liver involvement in systemic diseases will aid in both diagnosis and treatment of patients with a wide range of medical conditions.